UK Inquiry Tracker

Clive Gould

PFD Report All Responded Ref: 2013-0357

Date of Report 16 December 2013

Coroner Nicholas Graham

Coroner Area Oxfordshire

Response Deadline est. 10 February 2014

Community health care and emergency services related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 10 Feb 2014

Coroner's Concerns (AI summary)

Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication with callers about estimated arrival times and potential delays.

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In the circumstances it is my statutory duty t0 report to you_ (1) The original call made by was allocated priority status which meant that should higher priority call be received (a red status call) then an ambulance would be diverted, which is what happened on two occasions, An internal audit of that call suggests that a different priority could have_been_given to July green the original call and the presenting concerns Of Mr Gould s status F recommend that SCAS review how they allocate priority to calls such a8 this one and identify whether any improvements to the allocation of priority shauld be given: (2) In evidence before the inquest SCAS indicated that there was little resilience in the system t0 tolerate absence or sudden sickness of personnel at certain times My recommendation is that SCAS look at the resilience , particularly in rural areas ta consider whether further resources may need to be deployed (3) The evidence from the family at the inquest was that they were informed that an ambulance would be arriving shortly Had they known that there was to be the delays that occurred because other calls had been given priority , they informed me that they could have used first aid resources avallable to them within the village such as locally trained first aiders etc. My recommendation is that SCAS review what information they give callers and to consider whether communication in relation to estimated times of arrival should be notified t0 callers or the possibility of delays

Responses

South Central Ambulance Service NHS / Health Body

11 Dec 2013

Action Taken
South Central Ambulance Service has extended Rapid Response Vehicle cover to 24 hours in Oxfordshire, Buckinghamshire and Berkshire. Rota match versus demand has also been reviewed. They have developed a Clinical Support Desk (CSD) within Emergency Operations Centre to support patients with clinical advice until a response is on scene. (AI summary)

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Dear Mr Graham Clive Gould Date of death: 18'h July 2013 Inquest held at Oxford Coroner's Court on 11th December 2013 Thank you for your letter tol dated 16th December to which have been asked to further investigate and reply to three concerns raised by the Coroner during the course of the inquest on the December 2013 The Coroner recommended that SCAS review the following three concerns: Concern 1 How SCAS allocate priority to calls and identify whether any improvements to the allocation of priority should be given SCAS response Currently SCAS operates the Department of Health licenced 999 triage software system called AMPDS. As this is a licenced tool all ambulance responses are determined at a national level. As & Trust we are required to maintain our AMPDS licence and ensure that call audits are carried out on a pre-determined percentage of inbound call volumes The AMPDS product has been developed by Priority Dispatch Corporation with comprehensive training programme that is prescriptive in nature and in order to be compliant all our Emergency Call Takers are required to meet the training standards and are audited on monthly basis. As we currently use AMPDS our Call Takers are required to ask pre-determined set of verbatim questions. Therefore to comply with AMPDS licence Call Takers are required to adhere to the scripts and responses to these pre-determined questions by callers will directly affect the response level assigned to the patient SCAS have recognised that AMPDS is dispatch tool as opposed to a clinical decision software support tool. SCAS are currently transitioning, with full support from our Commissioners, from the AMPDS system to a more clinically focused assessment system called NHS Pathways which is also fully licensed by the Department of Health: The benefits of this change will be to quickly identify patients in a life threatening situation and dispatch accordingly for those patients who are more time critical and then to allocate remaining resources only if clinically required to do so. This transition will be completed by the end of autumn 2014_ Registered Headquarters: and 8 Talisman Business Centre, Talisman Road, Bicester 0X26 6HR 11t the

Concern 2 SCAS look at the resilience, particularly in rural areas; to consider whether further resources may need to be deployed SCAS response A review has been undertaken of overnight cover and Rapid Response Vehicle cover has now been extended to 24 hours in Oxfordshire, Buckinghamshire and Berkshire. This will provide additional resilience against short term sickness and wider geographical deployment cover in rural areas overight_ Rota match versus demand has also been reviewed with crew's now starting duty earlier in the morning to bridge an identified gap_ The forecasting demand approach has continued to develop and is working within reasonable levels of tolerance of accuracy enabling resources to be effectively planned We are also about to commence co-responding pilots with the Fire Service in both Oxford and Buckinghamshire which will further enhance our capacity to respond particularly in the rural areas Concern 3 SCAS review what information they give callers ad to consider whether communication in relation to estimated times of arrival should be notified to callers or the possibility of delays SCAS response SCAS has reviewed this point and conclude that as our 999 service is a dynamic response service situations and priorities can change and diverting of resources to a more time critical incident can happen and must take priority. Currently no ambulance service communicates at the time of a call what their response time will be for this reason: SCAS have recognised that on occasions patients may experience a delay in response due l0 high levels of demand In order to support patients SCAS have developed a Clinical Support Desk (CSD) within Emergency Operations Centre who will call back and support patients with further clinical advice until a response is on scene, The CSD are very experienced nurses and can support these patients and their families hope this to clarify our current arrangements-and improvements at SCAS and if you need any further information please do not hesitate to make contact;

Sent To

South Central Ambulance Service NHS Foundation Trust

Response Status

Linked responses 1 of 1

56-Day Deadline 10 Feb 2014

All responses received

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On 22 July 2013 an investigation commenced into the death of Clive Gould, who was 76 years old. The investigation concluded at the end of the inquest on 11 December 2013 The narrative conclusion of the inquest was that Mr Gould died on the morning of 18 2013 and that a ambulance was called at 4;18am but did not arrive until 5.47am, the medical cause of death being Congestive Cardiac Failure_

Circumstances of the Death

Mr Gould had complex past medical history ofsmall cell lung cancer , pulmonary embolism, vasculitis, interstitial lung disease, emphysema, atrial fibrillation , hypertension , left ventricular dysfunction and previous bladder cancer_ He was receiving chemotherapy for his lung cancer and had last received treatment on 17 July 2013. During the early hours Of 18 July he awoke complaining of sickness and shortness of breath and his wife rang the ambulance at 4.18am. Despite five follow up calls the ambulance did not arrive until 5.47am. Sadly, Mr Gould had gone into cardiac arrest by the time the ambulance arrived and could not be revived
5. At 6.22am death was confirmed

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action. My recommendations in respect of reviews to be carried out are set out above